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Cycle 8 (2019 Deadline)
Promoting hand hygiene through production and use of locally produced alcohol hand-rub in health facilities in Uganda
PI: Esther Buregyeya (eburegyeyeya@musph.ac.ug), Makerere University School of Public Health
U.S. Partner: Christine Moe, Emory University
Project Dates: April 2020 - December 2022
Project Overview:
Water, sanitation, and hygiene in healthcare facilities (HCFs) are critical for the provision of quality health care and prevention of hospital-acquired infections (HAIs). The healthcare-associated pathogens that can lead to HAIs are mainly transmitted through contact with contaminated hands of healthcare workers. HAIs represent the most frequent adverse event affecting hospitalized patients, resulting in increased morbidity and mortality. These infections are even more dangerous in this era of increasing anti-microbial resistance (AMR). Effective infection prevention and control measures prevent HAIs and help contain AMR. In particular, hand hygiene is recognized as the single most important practice to reduce HAIs and has been associated with sustained decrease in the incidence of AMR infections in healthcare settings. Though the importance of hand hygiene is well documented and recognized, evidence shows healthcare workers’ compliance is suboptimal in many settings, including Uganda. Factors found to affect hand hygiene compliance include poor access to sinks and hygiene supplies. Availability of an alcohol-based hand-rub at the point of care has been shown to increase hand hygiene. Alcohol-based hand-rub is currently recommended as the primary tool for hand hygiene action and promotion because it reduces bacterial counts on hands more effectively and can be more accessible than sinks. In addition, it can be locally produced at the HCF, making it even more accessible. However, locally made alcohol hand-rub intervention and research is limited in Ugandan UCFs.
To address this problem, the PI Dr. Esther Buregyeya and her team will develop a behavioral intervention to foster hand hygiene compliance using locally-produced alcohol- based hand-rub and assess the acceptability, feasibility, effect, and cost of using such hand-rub on compliance among health care workers in primary HCFs in Uganda. Expected outcomes of the study include improved hand hygiene and newly acquired skills in alcohol hand-rub production. U.S. partner Dr. Christine Moe is an experienced WASH expert in Uganda and other sub-Saharan countries who will contribute her knowledge and experience to facilitate the implementation of the study. The project fits well with the goals of Uganda and USAID in addressing the challenges of communicable diseases, with a focus on AMR and other emerging infectious diseases. Uganda is facing a mounting challenge of antibiotic resistance and recently launched its AMR National Action Plan (NAP). It also has a One Health Strategic Action Plan that includes work to address AMR. Hand hygiene is one of the most effective interventions to prevent HAI and reduce the transmission of resistant organisms. Therefore, this research will be timely in providing much-needed evidence about effective interventions that can inform implementation of the NAP and help ensure the future safety of patients, health workers, and communities in Uganda. In addition, recent global public health emergencies, such as Ebola disease outbreaks, have highlighted gaps in infection prevention and control (IPC) measures. Uganda lies in the Ebola “hot zone” and has experienced repeated outbreaks, including in 2019 in the neighboring Democratic Republic of Congo. In this situation, alcohol-based hand-rub is a very essential component of IPC. Therefore, developing interventions to foster hand hygiene compliance, such as promoting locally-produced alcohol-based hand rub, is critical for general health system resilience in Uganda and sub-Saharan Africa.
Final Summary of Project Activities:
This project on hygiene and infection control ended up being extremely timely, as it began in April 2020, at the start of the COVID-19 pandemic. The study involved three rounds of unannounced hand hygiene compliance observations in the four study facilities to establish the level of compliance with hand hygiene guidelines among the health workers in the study units. Those compliance rates ranged from a low of 35% to a high of 57%. The team found that a lack of sinks, water, and single-use towels was often a significant hindrance, highlighting the important role that could be played by increasing the use of alcohol-based hand sanitizers. One publication by the team is under review as of August 2023, and Dr. Buregyeya and her team are still analyzing their findings to prepare additional manuscripts. In addition, they conducted the bi-monthly continuous medical education (CME) training sessions in all the four study facilities, with the participants including laboratory technicians, clinicians, midwives, nurses, pharmacists, infection prevention and control (IPC) committee members, and health facility leadership representatives. During the CMEs, they emphasized the need for hand washing, disseminated results from the previous hand hygiene observations, and awarded the best performing health facility units with certificates of recognition and tea supplies.
Because of this project's work in promoting hand hygiene among health workers, the PI Dr. Buregyeya was invited to join a team funded by the U.S. Centers for Disease Control and Prevention (CDC) working on the development of an Infection Prevention Control (IPC) Fellowship and a postgraduate diploma IPC curriculum for health workers in Uganda. This is being done at a national level, and the PI’s department will host the program. The IPC fellowship had its first intake of seven fellows in June 2023. Relatedly, the PI used her experience on this project to apply for and receive a Tropical Health and Education Trust (THET) grant in the amount of 55,000 UK pounds to train healthcare workers in IPC, including local production of alcohol hand-rub and antimicrobial stewardship. Dr. Buregyeya also won a $100,000 grant from Pfizer on using a behavioral approach to design an antimicrobial stewardship intervention in healthcare facilities in Uganda.
Master’s of Public Health student Ms. Eunice Ekyakunda used her experience on the PEER project to help her prepare her recently submitted dissertation, which she also aims to submit for publication in a peer-reviewed journal. In addition, the chemist on the study team, Mr. Fred Twinomugisha, was inspired by the project activities to select as his PhD dissertation topic “The role of patient involvement in promoting hand hygiene practices among healthcare workers in Mukono and Kagadi districts: a mixed methods study.”
Outreach was a large part of the project to ensure that the team’s findings reached policymakers and clinicians. In designing their intervention, the researchers convened a stakeholder insight workshop to refine and co-create their plans. Later, they presented two posters virtually to the 2021 International Meeting on Emerging Diseases and Surveillance (IMED) and disseminated the study findings in the four participating health facilities. The team also made a project presentation the National IPC community of practice hosted by the Ugandan Ministry of Health in which they raised awareness of the project activities and achievements and disseminated some of the findings to several stakeholders. This was a countrywide event attended by more than 100 health workers and policymakers from
across the country.
Overall, Dr. Buregyeya points to several key achievements from her project. She and her team built capacity in the production of alcohol-based hand sanitizer in settings where hand hygiene infrastructure is poor and such sanitizer offers the most feasible alternative. Their PEER-supported work has also translated into long-term effects of developing a curriculum in IPC for health workers, in which training in the local production of alcohol-based hand rub is a key practical component. Finally, work on this project has translated into key AMS interventions aimed at improving the quality of healthcare services, including containing the development of antimicrobial resistance, a growing challenge in Uganda.
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